HomeMy WebLinkAboutPLBG2022-003107rexas C-0111IMSS1011 011 l-"J1ViR.)un1e11Wl QLM'i!V
BACK171.0"'PREVENTION ASSEMBIATEST AND MAINTENANCE RFTORT
Th,' $k,Howm torm mu: l hc lctM t , W C;ich tewd A �i,nwd and itawd on ina) mu.�t bd uhjume,l io the ti;Aw wate-, q.,, iwr for fecul'Aev, in u
NAIME OFTWS: Grapevine, Texas
P�VS fD#.- #2200013
PWS MAILING ADDRESS: 60 i Shady Brood Dr Grapeme, Tx 76051
PW',S CON'TACTPERSON: Backflow Coordinator, Jvmny Brock
ADDRESS OF SEKRVJC.T1- 4(,4vK
The backilow prevention abscmblv dctiiiled below has been te,�,ted and maintained as required by comnnis�Ion regulations
TYPE OF BACKFIX)NA'PREVENTION ASSEMBLY 01PA):
Reduced Pressure Principle (RPB A) Reduced Pressure !-r-mciple-Detector it PBA-D) Type It D
Double Check Valve (DCVA) 0 Double Check -Detector (DCVA-D) Type 11 ri
Pressure Vacumn Breaker (pVB,) Spill -Resistant Pressure Vacurim Breaker (,SVl3)
ManufaCturn i- Size: BVpa�S:
Model Number: Nljin: tF 00q Qf- 13c pa N s:: B I )A Location: teAe" 0
Serial Number: M ai ri 14 C, Lf '7 -7 B vpasN: 13PA Serves:
Reasciii fortSt' N c Nv Exismig Replacement D Old Nlodel/Serial #:
Is Lfreassembiv insuilled inaccordance with nianufacturer recommesidations an(Vor local Codes?
Yes El N o
Is the assembi k1sta es gNo
yl fled on a non -potable water supply �auxiliary)'�
............ . ... .... . . . ....
TEST RESULT' Type 111
Reduced Pressure Principle Assembly (RPBA) Assembly PV13 &,SVB
PA SS DCVA
Reliet'Valve Bypass Check Air hilet. Check Valve
FAIL L3 I Check
INAd �11 psid t I&I at at ,I jell al med at Initial Test psid opei)ed psid 7�01)� psid Held at
Date: 7"
psid
Cfoscd'['i,,�A E] Did flot ("'IC11 Goscd,right C-1 osed'f) ght
1,1* tile: Did not Did it fu I I v tked
1:: LeAcd Le�aked Leaked Lc�
open
AN,e4 LO /No 0)
Reparrs and Main-
'taterial S
BN pass:
�;Test After Held lit A leld �o -,id:,0jvjwd ai psid Held at risid Ctocned it( psid j Helda
R,;ed ep—air ;Closed'l,ight Chl
Dme: Tii
fime:
check numeric readffl..,, re, iulired for DCVA on1:1
Differential pressure gauge used:
Makc,"Oodei: Nfldwest 845-5 SNP 122!1503
Remarks:
Non-PorabloD
Date tested for amwacy
Comparty Name: aaa BacktiowLLC Ucen,�ed Tester Name
,
(Print/T, :,e):
Company Address: o box 173453 i-icensecrrester qamc (Signature):
p
Tx 76003
Chr/AeFrancis
817-975-6500 B PAT License # E3P 0012038
1 kxose EA °i ration Date: 3-23-24
The above is certified to be true at the three. oftesting,
�'['ESI'RECORDS MLIST RF KFiyl FOR A'f'[.I,,,AS'l''I'liki�"t.Yt?'ARS 1-,Wl A(.'r' kNO-4603)1